Resolution of Peripheral Artery Catheter-induced Ischemic Injury Following Prolonged Treatment with Topical Nitroglycerin Ointment in a Newborn: A Case Report

Abstract

Tissue ischemia, necrosis, and gangrene are uncommon but well-described complications of arterial catheterization in the neonate. Treatment options for progressive tissue necrosis following arterial embolization and/or vasospasm are limited in these patients secondary to unpredictable pharmacokinetics and risks associated with systemic anticoagulation or vasodilatation in newborns. We report a case of a multidose regimen of topical 2% nitroglycerin ointment for reversing severe tissue ischemia following peripheral arterial line placement. The favorable response in this infant suggests that topical nitroglycerin therapy should be considered as potential therapy to ameliorate the effects of vascular compromise following arterial line placement in neonates.

High-Dose Tissue Plasminogen Activator, Topical Nitroglycerin, and Heparin for Severe Ischemic Injury in a Neonate

“…The increased cGMP level causes vasodilatation and improved collateral circulation to areas of peripheral ischemia. 8,9 Hypotension, reduced cardiac output, and methhemoglobinemia occasionally seen with NGC 9 therapy did not occur in our patient, except for limb edema, which probably resulted from the venous pooling effects of NGC. Reduction of edema occurred with elevation of the limb, and the application of a xeroform gauze dressing resulted in healing of venous stasis ulcers.…”

“…6,7 NGC had a salutary and synergistic effect with tPA in our patient as is evident from the fact that ischemic changes recurred in the toes and sole of the left foot when NGC was briefly discontinued. Although topical NGC has been used singly in neonates with arterial ischemia, 8 our report is the first description of its use in conjunction with tPA and heparin. NGC is absorbed through the skin and exerts its pharmacological action by the production of nitric oxide (NO).…”

Topical Nitroglycerine for Neonatal Arterial Associated Peripheral Ischemia following Cannulation: A Case Report and Comprehensive Literature Review

“…Currently, there are 4 published studies on the use of topical nitroglycerin in neonates for the reversal of peripheral ischemia due to arterial cannulation. These involve 7 preterm infants (gestational age range 23–33 weeks), and the outcomes are uniformly positive (Table 1) [37–39, 46]. Our report in which repeated doses of topical nitroglycerin relieved distal ischemia and resulted in complete resolution and normal perfusion of the affected hand adds to the existing case series.…”

Topical nitroglycerin in neonates with tissue injury: A case report and review of the literature

“…Thrombolytic and anticoagulation therapies and local infiltration of phentolamine or hyaluronidase are of very limited benefit in the infant population, and their use demands either systemic administration or cutaneous injection (4)(5)(6). This has led many of the intensive care unit practitioners to err on the side of caution and rely solely on conservative management, accepting the high risk of long-term morbidity.…”